Download Intervention Technique using Transvenous Patent Ductus Arteriosus

Original Article
Intervention Technique using Transvenous Patent Ductus
Arteriosus (PDA) Occluder in a Dog
Chollada Buranakarl1* Anusak Kijtawornrat1 Wasan Udayachalerm2
Sirilak Disatian Surachetpong3 Saikaew Sutayatram1 Pasakorn Briksawan4
Suwicha Chuthathep4 Rampaipat Tungjitpeanpong5 Nardtiwa Chaivoravitsakul5
Abstract
The first case interventional technique of Patent Ductus Arterious (PDA) correction was conducted in a 2 years
old Golden Retriever. The dog was presented with continuous murmur with a marked left-side heart enlargement,
insufficiency of pulmonic, mitral, and aortic valves. The definitive diagnosis for PDA was performed by
echocardiography. The dog received PDA correction with interventional PDA occluding device consisting of nitinol
wire mesh under fluoroscope at the Small Animal Teaching Hospital, Faculty of Veterinary Science, Chulalongkorn
University with collaboration by medical expertise from Faculty of Medicine, Chulalongkorn University. The
procedure was successful as measured by complete occlusion of PDA and no major complication. At one month after
correction, the dog was more healthy and energetic while echocardiography showed a reduction of left ventricular
dimension and improved valvular insufficiency. At six months after correction, the dog had smaller heart size with
improved cardiac function.
Keywords: dog, PDA occluder, intervention technique
1Department of Physiology, 3Department of Medicine, 4Department of Surgery,
5Small Animal Teaching Hospital, Faculty of Veterinary Science, Chulalongkorn Univerisity
2 Department of Physiology, Faculty of Medicine, Chulalongkorn Univerisity Pathumwan, Bangkok, 10330, Thailand.
*Correspondence: [email protected]
Thai J Vet Med. 2015. 45(4): 593-602.
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Buranakarl C. et al. / Thai J Vet Med. 2015. 45(4): 593-602.
Introduction
Patent ductus arteriosus (PDA) is a congenital
heart disease that found in both humans and animals
in which the vessel connected between aorta and
pulmonary artery is not vanished after birth. The
changes in smooth muscle wall made the vessel
maintained its structure without constriction and
fibrosis. Thus, the oxygenated blood from left ventricle
can be passing through the main pulmonary artery
during ejection called “left to right shunt”. Since the
workload of the left heart increases to maintain
sufficient cardiac output, the left ventricular wall
becomes hypertrophy and dilated. The animals may
show signs of exercise intolerance when they are
puppy and the disease may become more progressive
up until the left heart failure developed along with
pulmonary edema. The correction has to be performed
as soon as possible after PDA diagnosis to prevent
animal from left heart failure and death.
The curative treatment by thoracotomy to
ligate the duct has been performed with success.
However, the procedure is highly invasive with high
incidence rate of postoperative complications. At
present, the interventional technique has been
introduced into human and veterinary medicine. The
transvenous catheterization to put the device into the
area of ductus for blood flow occlusion has been
performed in human worldwide. In dogs, the first
transvascular occlusion of PDA was reported by Miller
and colleagues (1994). Many devices including coil
and mesh have been used to occlude PDA with varying
indications and outcomes (Singh et al., 2012). This is
the first case report in Thailand to correct PDA using
interventional PDA occluding device with excellent
outcome.
History
A two years old spayed female Golden
Retriever weighting 31 kg was present to Small Animal
Teaching Hospital, Chulalongkorn University,
Bangkok, Thailand, with history of heart murmurs and
abnormal echocardiography assessed by local
Veterinarians without obvious cardiovascular signs.
Figure 1
No exercise intolerance or syncope was found while
she was exercised regularly. Physical examination
revealed high heart rate, normal lung sound, and
continuous heart murmur grade IV/VI with point of
maximal intensity (PMI) at base of the heart on the left
side. The patent ductus arteriosus was suspected while
further tests were performed to rule out other
congenital cardiac diseases.
Diagnosis
Routine blood collection and blood gas were
performed and the results were within normal limits.
The thoracic radiograph was performed and showed
left heart enlargement on both ventrodorsal and lateral
views with vertebral heart score of 13.5.
The
pulmonary congestion and mild edema were also
noticed (figure 1). The electrocardiography was
recorded and showed heart rate of 91 beats per minute
of normal sinus arrhythmia with tall R-wave (4.4 mV)
(figure 2). For the definite diagnosis of PDA, the
echocardiography was performed by the experienced
sonographer using 2-4 MHz phase array transducer
and ultrasound machine (Eko7 Cardiovascular
Ultrasound System, Samsung Medison).
The
examination was conducted without sedation when
the dog lying down in right and left lateral
recumbence. Enlarged left atrium, ventricle and
pulmonary artery were seen on two-dimensional
echocardiography (figure 3).
Doppler on twodimensional echocardiography revealed functional
mitral, aortic and pulmonic valves insufficiency.
Continuous turbulent flow was observed within
pulmonary artery. Spectral Doppler showed upright
saw tooth flow pattern with velocity 4.28 m/s and
pressure gradient at least 73.33 mmHg (figure 4).
Increased aortic flow velocity was observed. On left
cranial transverse view, the ductus with minimal
ductal diameter 6.8 mm and ampulla diameter 15.6
mm was measured. The cardiac dimensions and
functions were evaluated as shown in table 1. The dog
was scheduled to have transcatheter intervention by
PDA occluder two weeks later.
Thoracic radiograph of ventrodorsal (left) and lateral (right) views showing the enlargement of the left heart with
pulmonary congestion and mild pulmonary edema.
Buranakarl C. et al. / Thai J Vet Med. 2015. 45(4): 593-602.
595
Figure 2
ECG recorded form PDA dog showed high voltage of QRS complexes.
Figure 3
Two-dimensional echocardiography on right parasternal view showed left atrial and ventricular enlargement (A). Color
Doppler of two dimensional echocardiography on right parasternal and transverse views showed mild mitral valve
regurgitation (B) mild aortic valve insufficiency (C) and mild pulmonic valve insufficiency (D). LA=left atrium; LV=left
ventricle; MV=mitral valve; AO=aorta; PA=pulmonary artery; RV=right ventricle.
596
Figure 4
Buranakarl C. et al. / Thai J Vet Med. 2015. 45(4): 593-602.
Velocity of blood flow and flow pattern through ductus assessed by continuous wave Doppler echocardiography on right
transverse view (A). Ductus oriented from pulmonary artery to aorta on modified left cranial transverse view of two
dimensional echocardiography (B). Color Doppler on two dimensional echocardiography demonstrating flow from
ductus to pulmonary artery (C). AO=aorta; PA= pulmonary artery
Treatment
Procedure for Transcatheter Patent Ductus Arteriosus
(PDA) Occlusion: On the operation day, the dog was
premedicated with midazolam (0.3 mg/kg, iv) and
fentanyl (5 µg/kg, iv) and anesthetized with etomidate
(1 mg/kg, iv). Dog was placed on right lateral
recumbency. After orotracheal intubation, anesthesia
was maintained by isoflurane 1.5-2% in 100% oxygen.
Morphine sulfate (0.5 mg/kg, im) was also given for
analgesia. Prophylactic antibiotic (cephazolin 25
mg/kg, iv) and intravenous fluid (Lactate Ringer
Solution 10 mL/kg/hr) were administered via cephalic
vein. The right inguinal region was prepared for
surgery by aseptic technique.
An incision
approximately 2-3 cm was made over the right femoral
triangle to visualize femoral artery and vein. The
Seldinger technique was used to place vascular access
sheets (figure 5) into femoral artery (5 Fr) and vein (6
Fr). Basically, the intravenous catheter was placed into
the vessel followed by advancing the guidewire
through the needle. After that the needle was removed
and the vessel dilator together with vascular access
sheet was advanced over the guidewire into the vessel.
Then the guidewire and the vessel dilator were
removed and the sheet was flushed with heparinized
saline. A heparin (3 iu/kg, iv) was given to the dog
before the beginning of cardiac catheterization.
Ductal Angiography: In order to determine the PDA
occluder size, the ductal ostium was visualized by
cardiac catheterization and angiography technique. In
this case, a pigtail angiographic catheter (Cook
Medical, Thailand; 4 Fr) was inserted into femoral
artery via the vascular access sheet.
Under
fluoroscopic guidance (Phillips® BV Endura), the tip of
the catheter was positioned near the ostium (cranial or
caudal) of the ductal ampulla. Angiography was
performed with a rapid rate of administration (15 ml/
s; dependent on catheter flow limitations) of non-ionic
iodinated contrast medium (Iohexol, Omnipaque® 300
mgI/ml, GE Healthcare, Shanghai, China) at a dosage
of approximately 1 ml per kg bodyweight through the
angiographic catheter in aorta. The contrast material
was injected via a dual-syringe power injector system
(Medtron® AG, Accutron CT-D, Germany) to identify
the position of the ductal ampulla. The size of the PDA
in this dog could not be seen clearly. Therefore, the size
of the PDA occluder was selected based on the
echocardiographic examination. In this dog, the
cocoon duct occluder (size 12/14/20 mm, Vascular
Innovations, USA) was selected. The number 12 is the
Buranakarl C. et al. / Thai J Vet Med. 2015. 45(4): 593-602.
device diameter at pulmonary artery, the number 14 is
the device diameter at descending aorta, and the
number 20 is the retention diameter.
PDA duct Occluder Deployment : After determination
of the PDA size, a 5 Fr 45 degree angled end-hole
catheter (Cook Medical, Thailand) was advanced into
the femoral vein and directed to the PDA. A 0.035”
straight, floppy tip exchange wire is directed through
this catheter lumen and advanced across the PDA into
the aorta. The length of the wire is 200 cm which is
approximately twice the length of the catheter. Then
the wire was maintained within the aorta while the
end-hole catheter was withdrawn. The delivery sheath
with its dilator in place (8 Fr, Figure 5) was directed
over the exchange wire and advanced across the
ductus into the aorta. The dilator was carefully
withdrawn into the sheath to minimize potential
damage while the sheath is passing through the duct.
The dilator and exchange wire were completely
removed when the sheath tip was inside the aorta.
Then a hemostasis valve (Figure 5) was applied on the
sheath end. The PDA duct occluder device (Figure 6)
was loaded under sterile saline to prevent air emboli
during deployment. Then the hemostasis valve was
removed and the loader tip was inserted on the sheath
and advancing the device into the lumen. The loader
was withdrawn from the sheath to prevent
hemorrhage and the duct occluder device was
597
advanced through the sheath lumen by pushing on the
delivery cable (figure 6) while the sheath tip was still
remained in the aorta. After the PDA duct occluder
device was exteriorized within aorta, the sheath and
device were withdrawn together until the disc stayed
within the ampulla with distal disc engaged with the
ostium. Gentle retraction was applied on the delivery
cable to keep the device in contact with the ostium.
Unfortunately, the PDA duct occluder device was too
small; therefore, the device was pulled back into the
pulmonary artery. A new PDA duct occluder device
(size 16/18/24 mm) was then used and the process of
occluder deployment was restarted again. After the
new occluder was in proper location, a contrast
medium (20 mL) was administered by hand injection
to document device position. Once the device is stable
with its casted shape, the manufacturer-supplied vice
pin was attached to the delivery cable and rotated in a
counterclockwise direction until the device was
released from microscrew. Then the cable and the
sheath were withdrawn together. After that the
vascular access sheath was removed from both femoral
artery and vein and a pressure was applied on the skin
over the vessels to stop bleeding. A combat gauze
trauma pad was used to stop bleeding before closing
the incision site with routine manner. Analgesic
(morphine sulphate, 0.5 mg/kg, iv) and another dose
of cephazolin were given and the patient was admitted
in the hospital for monitoring.
Figure 5
Shows catheters for
Seldinger technique and
delivery sheath with its
dilator.
Figure 6
Shows
PDA
duct
occluder device attached
to the delivery cable. The
loader catheter and
hemostasis valve are
also included in this
picture.
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Buranakarl C. et al. / Thai J Vet Med. 2015. 45(4): 593-602.
Immediately after PDA was corrected, the
machinery murmur was disappeared and HR was
suddenly dropped down to approximately 40-60 bpm
with normal systolic blood pressure. Post-operative
medications
included
antibiotic
(amoxicillinclavulanic acid) and analgesic drugs (tramadol). No
major complication was found with minimal swelling
at the surgical site. Three days after device occlusion,
echocardiography revealed the left atrium and
ventricle were decreased in size. However, the mild
functional mitral and aortic insufficiency as well as
Figure 7
trivial functional pulmonic insufficiency was observed.
Two-dimensional echocardiogram revealed the device
in ductus on modified right parasternal short axis view
and modified left cranial transverse view (figure 7). No
turbulent flow was detected in the pulmonary artery
suggesting the PDA was occluded completely. The
pulmonary artery flow could be measured with
maximal velocity 1.14 m/s with pressure gradient 5.24
mmHg. The dog was discharged on day 3 after
surgery.
Two-dimensional echocardiography demonstrating device in ductus on right parasternal short axis view (A) and modified
left cranial transverse view (B). PA = pulmonary artery; PV = pulmonic valve. Color flow Doppler and spectral Doppler
echocardiography demonstrating flow in pulmonary artery with velocity 1.14 m/s and pressure gradient 5.24 mmHg after
device occlusion on modified right parasternal short axis view (C).
Thirty days after device occlusion, the size of
aortic root was decreased. Mild functional mitral,
aortic and trivial pulmonic insufficiency was seen.
Fractional shortening was still lower than normal limit.
However, left ventricular chamber dimension during
systole and diastole were decreased. One hundred and
eighty day after device occlusion, echocardiographic
examination revealed the decrease of jet sizes in all
valves (mitral, aortic and pulmonic valves). The FS and
EF were higher than one month after occlusion. The
echocardiographic values before and after correction of
PDA were shown in Table 1.
Discussion
Patent ductus arteriosus is a congenital heart
disease commonly found in many small and large
breed dogs (Buchanon, 1992).
The abnormal
development of smooth muscle of the duct leads to the
post-partum closure failure of the vessel that
connecting between aorta and pulmonary artery. In
case of PDA, structures involved in the shunt pathway
including descending aorta, pulmonary artery, left
atrium and left ventricle are usually enlarged.
The diagnosis of PDA is based upon the
echocardiography. The left cranial transverse view is a
better view to reveal the ductus compared to the right
transverse view (Schneider et al, 2007). The upward
saw toothed flow profile is a pathognomonic flow
pattern of PDA. This pattern occurs secondary to the
difference of pressure between aorta and pulmonary
artery during systole and diastole. Pressure gradient
between aorta and pulmonary artery should be closed
to 100 mmHg. As in this dog, the pressure gradient was
Buranakarl C. et al. / Thai J Vet Med. 2015. 45(4): 593-602.
around 70 mmHg. A high aortic flow velocity
suggested a significant ductal shunting in this dog.
Measurements of ductal size can be performed using
echocardiogram.
Size of ductus measured by
echocardiogram has been suggested to be closed to a
true size measured by angiogram (Saunders et al,
2007). This dog has a larger ampulla diameter
compared to a minimal ductal diameter confirming a
tapering type of ductus, which is fitted for catheter
based occlusion of PDA (Schneider et al, 2007).
The pulmonary artery usually dilates at the
level of the pulmonic valve and the right and left main
pulmonary artery branches (Boon, 2011). Flow from
Table 1
599
ductus is up toward the pulmonary valve which may
cause pulmonic valve prolapse or cusp annulus
dilatation causing insufficiency (Boon et al, 2011) as
seen in this dog with mild pulmonic insufficiency. The
dog in this report also had a decrease in % fractional
shortening and % ejection fraction similar to results of
Hamabe and colleagues (2015). This is because systolic
wall stress is not elevated due to the far away shunt
and the left ventricular free wall and interventricular
septum are inadequate hypertrophy during systole
(Van Israël et al, 2002).
Echocardiographic value before and after device occlusion groups
Parameter
Before
3 days after
30 days after
180 days after
reference*
Ao diameter (mm)
25.4
27.2
22.4
23.5
17.0-30.7
LA diameter (mm)
41.4
33.4
39.8
41.4
21.5-36.8
LA/Ao ratio
1.63
1.23
1.78
1.76
0.8-1.1
IVSd (mm)
11.3
11.8
11.5
11.6
10.3-11.5
LVd (mm)
67.2
61.9
52.7
49.4
32.3-43.9
LVPWd (mm)
10.3
12.3
11.5
10.3
8.3-9.3
IVSs
11.8
15.8
15.8
12.7
15.7-17.0
LVs
49.8
54.4
44.7
39
19.0-29.2
LVPWs
14.6
12.7
14.8
13.6
13.4-14.7
%Fractional shortening
25.87
12.06
15.18
20.95
33-46
%Ejection fraction
49.67
25.51
31.87
42.50
50-60
AV max (m/s)
2.84
1.24
1.24
1.18
<2
PV max (m/s)
n/a
1.14
1.44
0.96
<1.6
*Boon (2011) Ao = aorta; LA = left atrium; IVSd = thickness of interventricular septum during diastole; IVSs = thickness of
interventricular septum during diastole; LVd = left ventricular dimension during diastole; LVs = left ventricular dimension during
systole; LVPWd = thickness of left ventricular free wall during diastole; LVPWs = thickness of left ventricular free wall during systole;
AV max = aortic flow; PV max = pulmonary artery flow
The correction of PDA showed positive effect
on survival and reverse cardiac remodeling in the longterm follow up (Saunders et al., 2014). The severity of
cardiovascular signs may depend on the ostium
diameter and other complicated cardiac disease. The
left to right shunt from PDA can induce the left side
congestive heart failure with systolic dysfunction if
PDA correction is not performed early in life.
Stauthammer (2015) suggested that the dogs with
congestive heart failure have an excellent outcome if
PDA occlusion is performed before one year of age.
Moreover, after PDA closure in dogs, the survival rate
was negatively correlated with clinical signs,
concurrent congenital heart disease and severe mitral
regurgitation (Saunders et al., 2014). Treatment of
choice includes a conventional surgical ligation.
However, it had higher risks and complications. The
mortality and complication rates after this surgical
procedure may be high. Therefore, the interventional
methods that are less invasive with high success have
been introduced in both human and animals.
At present, both the occlusion devices and
procedures have been developed to introduce occluder
via transvenous or transarterial intervention.
Introductions of device occluder using vascular
catheters have been used and published (Snaps et al.,
1995, Grifka et al., 1996, Schneider et al., 1996, Fellows
et al., 1998, Fox et al., 1998, Glaus et al., 1999, Glaus et
al., 2002). Among these catheter techniques, the
transarterial coil-occlusion is a non-invasive and safe,
but it is suitable for dogs with small diameter of ducts.
This technique also showed several complications
included incomplete ductal closer, ductal reopening,
death, transient hemoglobinuria, hemorrhage,
600
pulmonary hypertension, and embolization (Campbell
et al., 2006). The most excellent outcome in dog is
transarterial Amplatzer Canine Duct Occluder
(ACDO) which composed of multilayer nitinol wire
mesh, compared with other interventions [i.e.,
transarterial Gianturco or Reye Flipper Detachable
Embolization (Flipper) coil, transarterial Amplatzer
Vascular Plug, and transvenous Flipper coil] (Singh et
al., 2012).
However, in the present case, the
transvenous occluder was chosen.
In term of choosing the device size, Glausand
coworkers (2002) suggested that the PDA occluder
device which was similar to the present study should
be 2 size larger than the PDA measured by contrast
injection. In the present study although the 12 mm
occluder (at pulmonary ostium) was chosen, the first
attempt was failed which may be due to an inaccurate
measurement of the ductal diameter using
echocardiography. The angiographic measurement of
the PDA in this dog could not be visualized due to
position of the tip of catheter or limitation of the
injector to overcome arterial pressure. One report
suggested that the size selection of the device by
angiography is dominated and could not be
substituted by echocardiography (Nguyenba and
Tobias, 2007). The second intervention was performed
with success when occluder with 4 mm larger than the
first device at pulmonary ostium was introduced.
Immediately after PDA closer, heart rate was
dropped to a normal value without murmur sound
suggesting the occlusion may be completed. The dog
was recovered quickly without complication. The
surgical size was swelling due to compression bandage
without vascular suturing.
Improvement of
hemodynamic indexes from echocardiography
occurred within 24 hour after occlusion. After PDA
closure, systolic function is commonly poorer. Percent
fractional shortening in this dog was declined to
12.06%. A decrease of fractional shortening may occur
secondarily to a decrease in left ventricular diastolic
dimension while the left ventricular systolic dimension
was unchanged or due to a decreased preload with an
increase in afterload after ductal closure (Campbell et
al, 2006). However, without afterload correction, the
contractility of left ventricle may actually not be
depressed. A decrease of fractional shortening and
ejection may persist for a long period of time after
ductal occlusion without clinical significance
(Stauthammer et al, 2013).
Moreover, mitral regurgitation is a common
finding in dogs with a PDA (Van Israël et al, 2003).
Mitral regurgitation still could be seen in large number
of dogs after ductal closure for a period of 9 to 121
months of study (Van Israël et al, 2003). This is
probably secondary to the degenerative changes of
valve leaflets due to high volume and velocity flow
across the valve (Van Israël et al, 2003), myocardial
dysfunction after ductal closure or mitral annular
dilation and papillary muscle displacement from
volume overload (Kittleson, 1998). Aortic insufficiency
may remain unchanged after ductal closure (Saunders
et al, 2007). This is probably because of the valve
damage or the aortic dilatation. An immediate stop of
the volume overload can be seen after successful
complete ductal occlusion (Stauthammer et al, 2013) as
Buranakarl C. et al. / Thai J Vet Med. 2015. 45(4): 593-602.
seen in this dog of which the size of left atrium and
ventricle was decreased after device occlusion for 3
days. Six months after device occlusion, the clinical
signs of dog were improved to nearly normal. The
echocardiographic data showed the reverse
remodeling in both anatomical and mechanical
functions. Although the data revealed lower FS than
before PDA correction, the improved cardiac function
with slow heart rate and reduced preload overcome the
lower FS to ensure that the progression of heart failure
was not compromised.
The process of PDA occlusion by
transcatheter method has become more common in
specialist animal teaching hospital in universities
worldwide.
This procedure is preferred over
traditional method (i.e. thoracotomy) because it has
rapid post intervention recovery and less postoperative complications due to avoidance of chest
surgery.
However, this procedure requires
appropriate facilities, instruments (i.e. fluoroscope,
coil, or occluder), and experienced operators. The
transcatheter method is also more expensive than the
open-chest surgery but it is worth for the patients and
owners.
In conclusion, a successful interventional
treatment was reported in dog with large PDA. The
dog was still full with high energetic and more exercise
tolerance with reduction of left ventricle size and less
valvular regurgitation within 1 month. The dog had
schedule to reevaluate at 3 months and 1 year after
PDA occlusion.
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บทคัดย่อ
การอุดหลอดเลือดพีดีเอ (Patent Ductus Arteriosus) โดยใช้เทคนิกอินเตอร์เวนชันผ่านหลอด
เลือดดาในสุนัข
ชลลดา บูรณกาล1* อนุศักดิ์ กิจถาวรรัตน์1 วสันต์ อุทัยเฉลิม2 สิริลักษณ์ สุรเชษฐพงษ์3
ทรายแก้ว สัตยธรรม1 ภาสกร พฤกษะวัน4 สุวิชา จุฑาเทพ4 ราไพภัทร ตั้งจิตเพียรพงศ์5 นาฏทิวา ไชยวรวิทย์สกุล5
การแก้ไขพีดีเอ (Patent Ductus Arterious; PDA) โดยใช้วิธีอินเตอร์เวนชันครั้งแรกในประเทศไทยกระทาในสุนัขพันธุ์โกลเดน รีท
รีฟเวอร์อายุ 2 ปี สุนัขเข้ารับการรักษาโดยตรวจพบเสียงผิดปกติของการเต้นของหัวใจแบบต่อเนื่อง มีภาวะหัวใจข้างซ้ายโตร่วมกับภาวะลิ้น
หัวใจพัลโมนิก ไมตรัลและเอออร์ติกรั่ว การตรวจวินิจฉัยได้รับการยืนยันว่ามีพีดีเอ ด้วยการตรวจคลื่นเสียงสะท้อนความถี่สูงที่หัวใจ สุนัขได้รับ
การแก้ไขพีดีเอด้วยวิธีอินเตอร์เวนชัน โดยใช้อุปกรณ์ที่ประกอบด้วยตาข่าย นิทิโนล (nitinol mesh) โดยกระทาผ่านกล้องฟรูโอโรสโคป ณ
โรงพยาบาลสัตว์เล็ก คณะสัตวแพทยศาสตร์ จุฬาลงกรณ์มหาวิทยาลัย ด้วยความร่วมมือกับผู้เชี่ยวชาญ คณะแพทยศาสตร์ จุฬาลงกรณ์
มหาวิทยาลัย การรักษาครั้งนี้ประสบความสาเร็จเป็นอย่างดี โดยอุปกรณ์อุดได้สมบูรณ์และไม่พบอาการแทรกซ้อนหลัก สุนัขแข็งแรงเป็นปกติ
และเมื่อตรวจด้วยคลื่นเสียงสะท้อนความถี่สูงพบว่า ขนาดหัวใจล่างซ้ายเล็กลงร่วมกับการรั่วของลิ้นหัวใจทั้งสามที่ลดลงภายหลังการแก้ไขครบ
1 เดือน
คาสาคัญ: สุนัข ตัวอุดพีดีเอ เทคนิกอินเตอร์เวนชัน
1ภาควิชาสรีรวิทยา 3ภาควิชาอายุรศาสตร์ 4ภาควิชาศัยศาสตร์
5โรงพยาบาลสัตว์เล็ก คณะสัตวแพทยาสตร์ จุฬาลงกรณ์มหาวิทยาลัย
2ภาควิชาสรีรวิทยา คณะแพทยศาสตร์ จุฬาลงกรณ์มหาวิทยาลัย ปทุมวัน กรุงเทพ ฯ 10330
*ผู้รับผิดชอบบทความ E-mail: [email protected]